CurrentNew Mexico Health Care AuthorityPolicy 8.324.10
Ambulatory Surgical Center Services — Reimbursement and Coverage
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State Medicaid rules governing eligibility, covered and noncovered services, utilization review, prior authorization, and reimbursement methodology for ambulatory surgical centers participating in New Mexico Medicaid.
Policy Summary
PayerNew Mexico Health Care Authority
PolicyAmbulatory Surgical Center Services — Reimbursement and Coverage
Policy CodePolicy 8.324.10
Change TypeNo material change
Effective DateJul 1, 2024
Last ReviewJul 1, 2024
Next Review Date
Key ActionCertain procedures may require prior authorization from MAD or its designee; providers must verify member eligibility at time of service.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
9surgical groups used to assign reimbursement levels
50%additional procedures paid
Hct/Hgb, UAroutine labs included
Yesimaging included in fee
2024-07-01effective
Ambulatory Surgical Center Coverage
Ambulatory surgical center coverage criteria
Covered when ALL of the following conditions are met:
Provider enrollment and certification: Provider must be enrolled with New Mexico Medicaid (MAD) and be a Medicare-certified free-standing ambulatory surgical center; centers that are part of an accredited and certified hospital follow hospital service rules.
Medical necessity: The surgical procedure and use of the facility must be medically necessary and covered by Medicaid; all Medicaid requirements for the surgery (such as applicable consent forms and any required prior authorization) must be met by the physician.
Facility services included in facility fee: All services furnished by the facility are considered reimbursed in the facility fee and cannot be billed separately; payment is the lesser of the facility's usual and customary charge or the maximum allowed by Medicaid.
Reimbursement methodology: Each surgical procedure is assigned to one of nine surgical groups based on procedure complexity; reimbursement level for the surgical group is used (Medicare carrier assignments are used when available; MAD assigns groups when Medicare has not established a reimbursement level).
Multiple procedures: When more than one covered surgical procedure is performed during the same surgical encounter, reimbursement is the rate for the most complex procedure plus 50% of the applicable rate for any additional procedures.
Laboratory services: The following laboratory services are included in the facility fee and are not reimbursed separately: hematocrit; hemoglobin (colorimetric); routine urinalysis without microscopy.
ASC laboratory reimbursement conditions: Laboratory tests not included in the facility fee will be reimbursed only if the ASC lab is separately CLIA-certified and enrolled, the tests billed fall within the certified specialties/subspecialties, the laboratory has an approved MAD provider participation application to bill those tests, and the tests are performed on the ASC premises (not sent to reference labs).
Diagnostic imaging and therapeutic radiology: Diagnostic radiology, diagnostic ultrasound, peripheral vascular flow measurements, and nuclear medicine furnished by the facility are covered but payment is included in the facility fee and are not separately reimbursed services.
Physician fees and dual-eligibles: Ambulatory surgical centers are not reimbursed for physician fees (physician services are paid directly to the provider). For Medicare–Medicaid dual-eligible recipients, Medicare is primary; Medicaid will not pay an ASC for a procedure denied by Medicare, and ASCs must refer such recipients to facilities Medicare pays for the procedure.
Billing submission: Claims must be submitted on the CMS-1500 claim form or its successor; providers receive instructions on documentation, billing, and claims processing once enrolled with MAD.
Coding and Reimbursement Details
Medicare-assigned surgical groupsmixed
| Medicare ambulatory surgery list | Medicare-designated list assigns procedures to surgical groups and is used to determine the assigned surgical group and reimbursement level. |
Multiple procedure reimbursement
Payment method for multiple proceduresMost complex procedure paid at full rate; additional procedures paid at 50% of their applicable rate
Applies toWhen more than one covered surgical procedure is performed during the same surgical encounter
Calculation detailReimbursement = rate for most complex procedure + 50% of applicable rate for each additional procedure
Prior Authorization and Utilization Review
Prior Authorization
Prior authorization, eligibility verification, and reconsideration rights
Certain procedures or services may require prior authorization from MAD or its designee; obtain prior authorization when required and follow the enrollment instructions and documentation forms provided to providers. Verify member Medicaid eligibility at the time services are furnished because prior authorization does not guarantee eligibility. If a prior authorization or utilization review decision is denied, providers may request a re‑review and reconsideration per the reconsideration process.
- Obtain prior authorization from MAD or its designee when the service/procedure requires it; services with prior authorization remain subject to utilization review.
- Verify Medicaid eligibility and any other health insurance at time of service—prior authorization does not confirm eligibility.
- If you disagree with a denial, request a re‑review and reconsideration as described in 8.350.2 NMAC.
Providers, Documentation, and Covered Services
Eligible providers
Required certificationMedicare certification under Title XVIII as a free-standing ambulatory surgical center
MAD enrollmentProvider must be approved via New Mexico medical assistance program provider participation application and enrolled with MAD
Hospital-based centersAmbulatory surgical centers that are part of an accredited and certified hospital are governed by hospital services rules (8.311.2 NMAC)
Provider responsibilities upon enrollmentOnce enrolled, providers receive and must maintain Medicaid policies, billing instructions, utilization review instructions and other materials from MAD
Documentation requirements
Record retentionProviders must maintain records that fully disclose the nature, quality, amount, and medical necessity of services furnished
Legibility and accessDocumentation supporting medical necessity must be legible and available to Medicaid upon request
Reference policySee 8.302.1 NMAC, General Provider Policies for additional documentation obligations
Covered services
Covered facility servicesFacility services are covered when the surgical procedure and facility use are medically necessary and covered by Medicaid
Physician requirementsAll Medicaid requirements for the surgery (e.g., applicable consent forms, prior authorization) must be met by the physician
Facility fee inclusionsCertain services (routine hematocrit, hemoglobin colorimetric, routine urinalysis without microscopy, diagnostic radiology, diagnostic ultrasound, peripheral vascular flow measurements, and nuclear medicine) are included in the facility fee and not reimbursed separately
Hospital rule exceptionCenters that are part of an accredited and certified hospital follow hospital service rules rather than ASC rules
Policy Summary
PayerNew Mexico Health Care Authority
PolicyAmbulatory Surgical Center Services — Reimbursement and Coverage
Policy CodePolicy 8.324.10
Change TypeNo material change
Effective DateJul 1, 2024
Last ReviewJul 1, 2024
Next Review Date
Key ActionCertain procedures may require prior authorization from MAD or its designee; providers must verify member eligibility at time of service.
SourceLink
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